Comprehensive Health Plan I

State of Maine • Augusta, ME

1d

About The Position

As a Comprehensive Health Planner I in the Program Integrity Unit, you will direct and conduct studies to identify and verify areas of fraud, abuse and waste in the MaineCare Program by using the Java Surveillance & Utilization Review System (J-SURS) among other programs. You will analyze large volumes of claims data to identify unusual or suspicious billing patterns, outliers, high volume or cost providers that may require additional follow-up. You will review/investigate allegations of fraud and abuse and conduct routine reviews of providers to verify compliance with MaineCare rules and regulations. You will determine areas of non-compliance and calculate overpayment amounts. You will prepare detailed spreadsheets of case review findings and when appropriate draft recoupment/sanction letters. You will assist the Healthcare Crimes Unit, OIG and the U.S. Attorney’s Office in case investigations when MaineCare policy and procedure expertise is required and/or when additional administrative review is needed.

Requirements

• A Bachelor’s Degree in Public/Community Health, Health Administration, Health Sciences or Health Education; Public Administration, Government, Social Work ,or a closely related field and two (2) years professional experience in the planning, development, coordination and/or evaluation of health programs or services -OR- an equivalent six (6) year combination of education, training, and experience.
• A demonstrated ability to identify, research and analyze a broad range of documents and data related to healthcare services and/or eligibility in order to verify compliance and/or identify potential fraud.
• Knowledge of and experience with nationally accepted billing forms and coding.
• Exceptional written communication skills to include the ability to develop written reports that summarize compliance/non-compliance.
• Knowledge and experience with medical terminology, Excel or comparable spreadsheet applications, MS Word or comparable word process application, Access or comparable database application and SharePoint or comparable file sharing application.

Responsibilities

• Direct and conduct studies to identify and verify areas of fraud, abuse and waste in the MaineCare Program by using the Java Surveillance & Utilization Review System (J-SURS) among other programs.
• Analyze large volumes of claims data to identify unusual or suspicious billing patterns, outliers, high volume or cost providers that may require additional follow-up.
• Review/investigate allegations of fraud and abuse and conduct routine reviews of providers to verify compliance with MaineCare rules and regulations.
• Determine areas of non-compliance and calculate overpayment amounts.
• Prepare detailed spreadsheets of case review findings and when appropriate draft recoupment/sanction letters.
• Assist the Healthcare Crimes Unit, OIG and the U.S. Attorney’s Office in case investigations when MaineCare policy and procedure expertise is required and/or when additional administrative review is needed.

Benefits

• Work-Life Fit – Rest is essential. Take time for yourself using 13 paid holidays, 12 days of sick leave, and 3+ weeks of vacation leave annually. Vacation leave accrual increases with years of service, and overtime-exempt employees receive personal leave.
• Health Insurance Coverage – The State of Maine pays 85%-100% of employee-only premiums ($12,845.82 - $15,112.76 annual value), depending on salary.
• Health Insurance Premium Credit – Participation decreases employee-only premiums by 5%.
• Dental Insurance – The State of Maine pays 100% of employee-only dental premiums ($395.72 annual value).
• Retirement Plan – The State contributes the equivalent of 14.11% of the employee's pay towards the Maine Public Employees Retirement System (MainePERS).
• Parental leave is one of the most important benefits for any working parent. All employees who are welcoming a child—including non-birthing and adoptive parents—receive six weeks of fully paid parental leave.
• Additional, unpaid leave may also be available, under the Family and Medical Leave Act.
• State employees are eligible for an extensive and highly competitive benefits package, covering many aspects of wellness.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees